Veterans Health PTSD 2012

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CONGRESS OF THE UNITED STATES

CONGRESSIONAL BUDGET OFFICE

CBO

The Veterans Health Administration’s

Treatment of

PTSD and Traumatic

Brain Injury Among

Recent Combat Veterans

FEBRUARY 2012


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Pub. No. 4097


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The Congress of the United States O Congressional Budget Office

A

S T U D Y

CBO

The Veterans Health Administration’s Treatment of PTSD and Traumatic Brain

Injury Among Recent Combat Veterans

February 2012


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Notes

Unless otherwise indicated, all years referred to in this study are federal fiscal years (which run

from October 1 to September 30).

Unless otherwise indicated, all dollar amounts in this study are expressed in 2011 dollars.Before providing cost data to the Congressional Budget Office (CBO), the Veterans Health

Administration converted those data to fiscal year 2009 dollars on the basis of annual

increases in the average cost of a primary care visit from 2004 to 2009. CBO indexed those

data to 2011 dollars using the implicit price deflator for gross domestic product. CBO also

converted other dollar amounts reported in this study to 2011 dollars using the implicit price

deflator for gross domestic product.

Numbers in the text and tables may not add up to totals because of rounding.


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Preface

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T wo combat-related conditions that affect some veterans who have served in Iraq and Afghanistan and that have generated widespread concern among policymakers are post-

traumatic stress disorder (PTSD) and traumatic brain injury (TBI). In response to a request

from the Ranking Member of the House Committee on Veterans’ Affairs, this Congressional

Budget Office (CBO) study examines the following:

The clinical care that the Veterans Health Administration (VHA), the health caresystem within the Department of Veterans Affairs, provides for recent combat veterans;

• VHA’s coordination with the Department of Defense for the care of service membersreturning from Iraq and Afghanistan;

• The prevalence of PTSD and TBI among veterans of those conflicts and the occurrenceof those conditions among recent combat veterans using VHA’s services; and

• The costs to VHA of providing care to recent combat veterans for those conditions.

In keeping with CBO’s mandate to provide objective, impartial analysis, this study makes no

recommendations.Elizabeth Bass and Heidi Golding of CBO’s National Security Division prepared the study

under the general supervision of David Mosher and Matthew Goldberg. Allison Percy

served as the internal reviewer. Lindsay Coleman, Juan Contreras, Sunita D’Monte, and

Ann Futrell provided thoughtful comments on a draft of the study, as did external reviewer

Rajeev Ramchand of RAND Corporation. (The assistance of an external reviewer implies

no responsibility for the final product, which rests solely with CBO.) Adebayo Adedeji fact-

checked the manuscript. The authors wish to thank the Department of Veterans Affairs and

the Department of Defense for providing data used in the analysis.

Juyne Linger edited the study, and John Skeen proofread it. Cindy Cleveland produced drafts

of the manuscript. Maureen Costantino prepared the paper for publication and designed thecover. Monte Ruffin printed the initial copies, and Linda Schimmel handled the print distri-

bution. The publication is available at CBO’s Web site ( www.cbo.gov ).

Douglas W. Elmendorf

Director

February 2012

http://www.cbo.gov/http://www.cbo.gov/


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Contents

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Summary vii

Introduction 1

Clinical Care Within VHA 3

VHA’s Services for PTSD 3

VHA’s Services for TBI 5

Concurrent Diagnoses of PTSD and TBI 6

Polytrauma 6

Cooperation Between VHA and DoD 7

CBO’s Analytical Approach to VHA Data 8

Occurrence and Prevalence of PTSD and TBI 10

Use of VHA’s Services 12

Number of Patients Using VHA’s Services 14

Frequency of Use 15

Costs of VHA’s Services 16

Costs of All Health Care 17

Costs of PTSD- and TBI-Specific Care 18

Other Studies of the Costs of Treating PTSD and TBI 20

Polytrauma Patients 21

Appendix A: Background on PTSD and TBI 23

Appendix B: Data and Methods 27

Appendix C: Interpreting Published Estimates of the Prevalence of PTSD and TBI 31

Appendix D: VHA’s Average Annual Costs for OCO Veterans Who Continue to

Seek Care 37


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VI THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

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Tables

S-1. The First Year of Treatment for All Health Care Provided toOCO Patients by VHA viii

1. Total Costs for VHA’s Health Care Provided to OCO Patients 18

2. Average Costs for All of VHA’s Health Care and VHA’s PTSD- andTBI-Specific Care Provided to OCO Patients 19

3. Use and Costs of VHA’s Health Care Provided to OCOPolytrauma Patients 22

D-1. Sample Sizes 38

D-2. Alternative Calculation of Average Costs for All of VHA’s Health CareProvided to OCO Patients 39

Figures

1. Continuation of Use of VHA’s Services by OCO Veterans 14

2. Use of VHA’s Health Care Services by OCO Patients 15

3. Average Costs for All of VHA’s Health Care Provided to OCO Patients 20

B-1. Years of Potential Use of VHA’s Services, by OCO Patient’s Year of Entry 28

Boxes1. Eligibility for VHA’s Services 2

2. Suicide and Mental Illness Among OCO Veterans 12


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Summary

More than 2 million service members havedeployed in support of overseas contingency operations(OCO) in Iraq and Afghanistan since October 2001.Some military service members receive medical care inthe combat theater for injuries or other medical condi-

tions sustained while deployed. Other service membershave combat-related medical conditions that are identi-fied and treated after they return from war—within theDepartment of Defense’s (DoD’s) health care system foractive-duty personnel and within the Department ofVeterans Affairs (VA) for veterans, including deactivatedreservists. VA provides health care services through theVeterans Health Administration (VHA), which treatsveterans for service-connected conditions and otherconditions.

VHA spent about $2 billion (in 2011 dollars) in fiscalyear 2010 to treat veterans of recent overseas contingencyoperations, compared with total expenditures in 2010 onhealth care for veterans of all eras and conflicts of about$48 billion. From 2002 through 2010, VHA spent a totalof $6 billion on health care expenditures for recent OCOveterans.

Two conditions that affect some military servicemembers during deployment to a combat theater andafterward are post-traumatic stress disorder (PTSD) andtraumatic brain injury (TBI). PTSD is an anxiety disor-

der induced by exposure to a traumatic event, such as witnessing injury or death. It is characterized by symp-toms that include reexperiencing the event, hyperarousal(irritability, anger, or hypervigilance, for example), anddiminished responsiveness to or avoidance of stimuliassociated with the trauma.

TBI is caused by sudden trauma to the head and is com-monly sustained by soldiers exposed to explosions. It mayresult in a decreased level of consciousness, amnesia, or

neurological abnormalities, and it is classified as mild,

moderate, or severe on the basis of its severity at the time

of the injury. Mild TBI, which is also known as a concus-

sion, may in some cases lead to ongoing symptoms that

include headaches, memory difficulties, fatigue, irritabil-

ity, and sleep problems. Diagnosing severe cases isstraightforward, but mild TBIs—which account for

about 90 percent of TBI cases among active-duty OCO

service members—may be difficult to detect, both by

those afflicted and by health care professionals, although

most cases resolve quickly without medical intervention.1

Some observers contend that DoD and VHA may not

adequately screen, diagnose, and treat OCO service

members and veterans affected by PTSD and mild TBI.

In this study, the Congressional Budget Office (CBO)

analyzes VHA’s care of OCO patients diagnosed withPTSD or TBI and compares the reported rates of occur-

rence of those conditions within VHA with estimates of

the prevalence of those conditions in the broader popula-

tion of service members who have deployed to recent

overseas contingency operations. (Prevalence estimates

gauge the proportion of cases of a disease or condition in

a population, whether or not people have received a diag-

nosis from a medical professional; by comparison, the

reported occurrence of conditions among the people

who have been treated within VHA reflects counts of

diagnoses by medical professionals.) The study also exam-

ines the costs that VHA has incurred in treating patients

diagnosed with PTSD and TBI.

1. Diagnosis of mild TBI with persistent symptoms is complicatedbecause the condition does not have a clinically validated defini-tion—that is, a definition that is based on a substantive body ofempirical research and is broadly accepted by the medical commu-nity. Moreover, many other conditions cause symptoms that aresimilar to those of mild TBI.


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Summary Table 1.

The First Year of Treatment for All Health Care Provided toOCO Patients by VHA

Source: Congressional Budget Office based on data from the Department of Veterans Affairs, Veterans Health Administration.

Notes: Data cover fiscal years 2004 to 2009 for the first year of treatment.

All of the TBI patients in the data that CBO examined had symptomatic TBI—that is, they exhibited symptoms that were attributed to

TBI at the time of VHA’s medical screening or examination.

VHA converted costs provided to CBO to fiscal year 2009 dollars on the basis of annual increases in the average cost of a primary care

visit from 2004 to 2009. CBO then indexed those costs to 2011 dollars using the implicit price deflator for gross domestic product.

OCO = overseas contingency operations; VHA = Veterans Health Administration; PTSD = post-traumatic stress disorder;

TBI = traumatic brain injury; * = less than 1 percent.

a. Patients in the PTSD group did not have TBI, but many had other conditions.

b. Patients in the TBI group did not have PTSD, but many had other conditions.

In brief, CBO finds:

Among OCO patients treated by VHA from 2004through 2009, 21 percent were diagnosed with PTSD(but not TBI) and 2 percent with symptomatic TBI(but not PTSD) (see Summary Table 1).2 An addi-tional 5 percent had both PTSD and TBI; thus, about75 percent of those diagnosed with TBI had a con-current diagnosis of PTSD. Seventy-two percent ofpatients had neither diagnosis. (CBO separatelyanalyzed another 500 polytrauma patients—that is,ones with complex, severe injuries to multiple organsystems.)

The average cost for OCO patients in the first year oftheir treatment was about four to six times greater forpatients with a diagnosis of PTSD, TBI, or both thanfor patients without those conditions.

VHA’s average costs for OCO patients were highest

during the first year of care and generally declined andthen stabilized in subsequent years.

For patients with TBI (including those with both

PTSD and TBI), however, VHA’s average treatment

costs appear to increase in the third and fourth years of

care. That result is probably driven by a policy change

that occurred in the middle of the period that CBO

analyzed and the nature of the data that VHA pro-

vided to CBO.3 In the absence of the policy change,

Treatment Group

PTSD or TBI

PTSDa 8,300 103,500 21

TBIb 11,700 8,700 2

Both PTSD and TBI 13,800 26,600 5

No PTSD or TBI 2,400 358,000 72

Polytrauma 136,000 500 *

Average Cost

(Dollars) OCO Patients

Number ofShare of AllOCO Patients

(Percent)

per Patient

2. All of the TBI patients in the data that CBO examined hadsymptomatic TBI—that is, they exhibited symptoms that wereattributed to TBI at the time of VHA’s medical screening or exam-ination.

3. VHA’s clinical practices for TBI changed during the data period(2004 to 2009): In 2007, the agency initiated comprehensivescreening for mild, symptomatic TBI. Therefore, patients whomVHA diagnosed with TBI in 2007 or later were more likely tohave had mild TBI than those diagnosed before that year. As aresult, the data that CBO analyzed included a smaller share ofpatients with mild TBI in their third and fourth years of treat-ment than in their first and second years. Because treating patients

with moderate or severe TBI requires more extensive services andresources than does treating patients with mild TBI, that differ-ence elevated the estimated average costs of treatment for TBIpatients in the third and fourth years.


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SUMMARY THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

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costs for those patients probably also would have beenhighest during the first year of care and then declinedand stabilized thereafter.

A great deal of uncertainty surrounds the prevalence ofPTSD and TBI within the OCO population and,hence, the number of veterans with those conditionsthat DoD, VHA, and other health care providers mayencounter in the future.

Projecting the future costs of treating veterans withPTSD and TBI requires estimating both the numberof patients with those conditions who will seek VHA’scare and the costs per patient that VHA will incur.Because the research community has not reached a con-sensus about the prevalence of those conditions, such

projections would be highly uncertain. CBO examinedpublished studies that reported the prevalence of PTSDor TBI among different groups of service members orveterans who had deployed to overseas contingencyoperations. For PTSD, those prevalence estimates havegenerally ranged between 5 percent and 25 percent. ForTBI, those estimates indicate that between 15 percentand 23 percent of service members may have experienceda TBI while deployed to an overseas contingency opera-tion but that a smaller share, between 4 percent and9 percent, are still symptomatic when screened afterreturning to the United States. Estimates of the preva-

lence of PTSD and TBI vary widely among studiesbecause of substantial differences in the assessment toolsthat researchers use to identify the conditions, the strin-gency of the criteria they employ, and the subgroupsthey sample. The percentage of OCO veterans whomVHA clinicians have diagnosed with PTSD (26 percent)is at the top of the range reported in published studies, whereas the percentage they have diagnosed with symp-tomatic TBI (7 percent) is in the middle of thereported range.

The rates of diagnosis of PTSD and TBI among OCOveterans seeking treatment at VHA do not necessarilyreflect the prevalence of those conditions in the entireOCO population. If veterans who suspected they hadmental health or other medical problems were more likely

than other veterans to seek medical care from VHA, therates of PTSD and TBI diagnosed among VHA’s patients would tend to overestimate the prevalence in the entireOCO population. However, some veterans might notseek care from VHA for various reasons—the stigmaassociated with having a mental health problem, forexample, or the inconvenience of undergoing additionalevaluation and treatment. If a sufficient number of veter-ans with PTSD and TBI did not seek care from VHA,the rates of diagnoses for those conditions among VHA’spatients would tend to underestimate the prevalence inthe OCO population.


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The Veterans Health Administration’s Treatment of

PTSD and Traumatic Brain Injury AmongRecent Combat Veterans

Introduction

The United States has been involved in overseas contin-gency operations (OCO) in Afghanistan and Iraq sinceOctober 2001 and March 2003, respectively, and hasdeployed more than 2 million service members in sup-port of those operations. The Department of Defense(DoD) delivers medical care to service members whilethey are deployed. That care includes nearly 4 millionmedical encounters since January 2005 for a variety ofconditions, including injuries; it also includes 71,000medical evacuations of service members from the combattheaters through November 2011. Both DoD and theVeterans Health Administration (VHA), the organization

that provides medical care within the Department ofVeteran Affairs (VA), screen for various conditions andprovide health care after service members return fromdeployment. VHA treated 400,000 (31 percent) of1.3 million eligible OCO veterans in fiscal year 2010,up from 100,000 (20 percent) of 500,000 eligible OCOveterans in 2005. Many eligible veterans do not seek careat VHA in any given year or at any time, and most VHApatients seek additional health care outside of VHA. (SeeBox 1 for information about eligibility for VHA’s healthcare system.) Although OCO veterans made up 7 percentof the patients VHA treated in 2010, they accounted foronly 4 percent ($2 billion) of the $48 billion (in 2011dollars) that VHA obligated for medical care that year.From 2002 through 2010, VHA spent a total of$6 billion on health care for OCO veterans.1

Two medical conditions that may affect OCO veteranshave received particular attention: post-traumatic stressdisorder (PTSD) and traumatic brain injury (TBI).PTSD is an anxiety disorder triggered by a traumaticevent, such as may occur when engaging in combat;

witnessing serious injury, brutality, or unnatural death,

particularly of another soldier; or suffering a severevehicle accident, including those caused by improvised

explosive devices (IEDs). The symptoms of PTSD

include reexperiencing the event, hyperarousal (irritabil-

ity, anger, or hypervigilance, for example), and dimin-

ished responsiveness to or avoidance of stimuli associated

with the trauma. TBI is a blow to the head that alters a

person’s consciousness, if only momentarily. TBI may

result in amnesia or neurological abnormalities at the

time of injury. In the combat theater, explosions from

IEDs or other bombs are a leading cause of TBI among

military personnel, although TBIs also result from falls,motor vehicle accidents, and bullet wounds.2 TBI is

classified as mild, moderate, or severe on the basis of

its severity at the time of injury. (That classification

refers to the acuteness of initial symptoms only, not

to that of persistent symptoms.) Mild TBI, also known

as a concussion, typically resolves quickly without

medical treatment, in many cases within weeks and

in most cases within three months. Although some

symptoms may linger for six months or more, there

is considerable debate over whether those persistent

symptoms can be attributed to mild TBI or to other

1. For a recent overview of those costs, see the statement of HeidiL. W. Golding, Principal Analyst for Military and Veterans’Compensation, Congressional Budget Office, before the SenateCommittee on Veterans’ Affairs, Potential Costs of Health Care forVeterans of Recent and Ongoing U.S. Military Operations (July 27,2011).

2. Defense and Veterans Brain Injury Center, TBI Facts,accessed June 27, 2011, at www.dvbic.org/TBI---The-Military/TBI-Facts.aspx .

http://www.cbo.gov/doc.cfm?index=12315http://www.cbo.gov/doc.cfm?index=12315http://www.dvbic.org/TBI---The-Military/TBI-Facts.aspxhttp://www.dvbic.org/TBI---The-Military/TBI-Facts.aspxhttp://www.cbo.gov/doc.cfm?index=12315http://www.cbo.gov/doc.cfm?index=12315http://www.dvbic.org/TBI---The-Military/TBI-Facts.aspxhttp://www.dvbic.org/TBI---The-Military/TBI-Facts.aspx


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CBO

conditions.3 (See Appendix A for more detailed informa-

tion about PTSD and TBI.)

Few service members have been evacuated from combattheaters as a result of PTSD or TBI alone, although many

have been evacuated for TBI in conjunction with other

injuries. Many cases of PTSD and TBI may go unrecog-

nized and consequently undiagnosed and untreated, both

in the combat theater and once the service member

returns home. PTSD can interfere with daily functioning when it results in emotional withdrawal from family and

friends, inappropriate expressions of anger, irritability,

overprotective behaviors, or substance abuse. Those with

ongoing mild TBI may feel sad, nervous, or agitated;

have difficulty concentrating and sleeping; and experi-

ence sensitivity to noise or light. Those with moderate

or severe TBI may experience similar difficulties but

also have more complex physical and neurological limita-

tions, which in some cases affect their ability to live

Box 1.

Eligibility for VHA’s Services

Eligibility for the health care system of the VeteransHealth Administration (VHA) is based primarily on aveteran’s military service. Generally, veterans of theactive components of the military must have served24 continuous months on active duty to be eligible;reservists and National Guard members may beeligible if they are called to active duty under a federalorder and they complete that service. Those broadcriteria, however, do not necessarily guarantee accessto medical treatment. VHA operates an enrollmentsystem that assigns a veteran to one of eight categories

to establish his or her priority for using its healthcare services. Veterans with higher priority includethose who have service-connected disabilities, lowincome, or both. In January 2003, VHA imposed ageneral freeze (with some subsequent modifications)on new enrollments in the lowest priority group(Priority Group 8).1

The Veterans Programs Enhancement Act of 1998(Public Law 105-368) guarantees access to VHA’shealth care system, after separation from active mili-

tary service, to members of the armed forces whohave served on active duty in combat operations sincethe law was enacted in November 1998; reservistsand members of the National Guard who have servedin combat operations are also included under thatguarantee. The law gave combat veterans two years(starting from their date of separation from the mili-tary) to enroll and use VHA’s health care system with-out requiring those veterans to document either thattheir income is below established thresholds or thatthey have a service-connected disability—require-

ments that noncombat veterans must fulfill. In 2008,lawmakers extended the enhanced eligibility periodfor care through VHA’s health care system to fiveyears.2 Under those legislative authorities, VHA pro-vides free health care for medical conditions directlyor potentially related to a veteran’s military service incombat operations for five years after separation.Veterans who had deployed to overseas contingencyoperations (OCO) may continue to use VHA’s ser-vices when the five-year period of enhanced eligibilityends, but their priority group for enrollment maychange, depending on their disability status and

income. In particular, OCO veterans may be movedto a lower priority group, including Priority Group 8,and incur the applicable copayments.

1. Veterans in Priority Group 8 are those who have no service-connected disabilities (or, according to a determination bythe Department of Veterans Affairs [VA], have service-connected disabilities that are ineligible for monetary com-pensation) and have annual income or net worth above VA’smeans-test threshold and regional income threshold. See

www.va.gov/healtheligibility/Library/AnnualThresholds.asp.2. See title XVII of the National Defense Authorization Act for

Fiscal Year 2008, P.L. 110-181, 122 Stat. 493.

3. For further discussion, see Susanne Meares and others, “TheProspective Course of Postconcussion Syndrome: The Role ofMild Traumatic Brain Injury,” Neuropsychology , vol. 25, no. 4(July 2011), pp. 1–12; and Charles W. Hoge and others, “Careof War Veterans with Mild Traumatic Brain Injury—FlawedPerspectives,” New England Journal of Medicine , vol. 360, no. 16(April 16, 2009), pp. 1588–1591.

http://www.va.gov/healtheligibility/Library/AnnualThresholds.asphttp://www.va.gov/healtheligibility/Library/AnnualThresholds.asp


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independently. Symptoms manifest themselves in differ-ent ways and with different intensity across people andsituations; some people function well in some settings butnot in others.

Some policymakers have questioned whether DoD andVHA have the resources and capacity to serve the OCOpopulation with PTSD and TBI. Some observers are alsoconcerned about whether service members and veterans with those conditions are reluctant to seek the help theyneed. In this study, the Congressional Budget Office(CBO) examines the clinical care provided by VHA forOCO veterans with PTSD and TBI, VHA’s coordination with DoD for the care of service members and veterans,the rate of occurrence of PTSD and TBI among VHApatients and the estimated prevalence of those conditions

in the broader population of recent OCO veterans, theuse of VHA’s health care services by OCO veterans whohave been diagnosed with PTSD or TBI, and the costs ofproviding that care. Because the prevalence of PTSD andTBI in the OCO population is highly uncertain, CBOhas not projected VHA’s future costs for treating veterans with those conditions.

Clinical Care Within VHA To serve the growing population of veterans, VHA hashired more than 7,500 mental health professionals since

2005 and has established specialized rehabilitation cen-ters for veterans with multiple complex injuries, includ-ing TBI. Further, VHA offers a broad range of servicesand programs tailored specifically to OCO patients withPTSD and TBI. In this section, CBO presents a briefoverview of typical strategies for diagnosing PTSD andTBI, along with treatment options that VHA provides forthose conditions.

VHA’s Services for PTSD As of September 2011, mental health diagnoses were thesecond largest diagnostic category among OCO veterans

who had received health care services from VHA, affect-ing 52 percent of those patients.4 VHA delivers PTSDcare in primary care settings and in specialized programsof evaluation, treatment, and education. Through itselectronic national clinical reminder system, VHA

endeavors to administer a screening test for various medi-cal conditions, known as the Iraq and Afghan Post-Deploy Screen, to all OCO patients.5 That screenincludes the Primary Care PTSD (PC-PTSD) screen,

which consists of four questions. VHA’s policy is toscreen for PTSD every year for the first five years a vet-eran uses VHA care and once every five years thereafter,except in cases in which a clinical need for more frequentscreening has been identified.

Veterans who screen positive for PTSD are referred foradditional evaluation. For most patients, further assess-ment is provided by a mental health professional such asa psychiatrist, psychologist, or trained clinician. Thatassessment typically takes place at a follow-up appoint-ment, although additional evaluation or a diagnosis may

occur during the visit when the screening occurs. VHAclinicians make their diagnoses according to the Ameri-can Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), which delineatesthe professionally certified criteria for mental disorders inthe United States. Diagnoses are made using a variety ofdiagnostic tools, often in combination, such as structuredinterviews (the Clinician-Administered PTSD Scale),semistructured interviews (the Structured Clinical Inter-view for DSM Disorders), and self-reported evaluations(the PTSD Checklist).

Although PTSD has a well-validated case definition anddiagnostic criteria, it can nonetheless be difficult to diag-nose and treat. First, some OCO veterans and servicemembers do not seek treatment for mental health prob-lems. Despite widespread outreach programs within themilitary and VHA, the stigma associated with mentalhealth disorders may discourage veterans from schedulingan appointment for an assessment or from requestingtreatment, and fear of harming one’s military career mayinhibit service members from seeking treatment whilethey are on active duty. Second, as with many mental

health disorders, there is no objective measure, such asa laboratory test result, for confirming a diagnosis ofPTSD. Third, some PTSD symptoms—for example,irritability, emotional numbing, insomnia, and troubleconcentrating—also occur with other conditions. Fourth,PTSD can impair judgment, especially if combined with

4. The largest category of diagnoses—diseases of the musculoskeletalsystem or connective tissue system—applied to 56 percent ofOCO patients. Veterans may receive diagnoses in more than onecategory, so the percentages of patients with different diagnosessum to more than 100 percent.

5. The screen for deployment-related health risks includes questionsdesigned to detect depression, alcohol abuse, and TBI, in additionto those relating to PTSD. The screen may be given in one ofseveral venues but commonly occurs during a primary care visit.


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associated conditions such as substance abuse, andthereby make it more difficult for veterans with PTSD toseek or maintain treatment.

VHA provides treatment for PTSD at VHA hospitals,outpatient clinics, community-based outpatient clinics(CBOCs), and Vet Centers.6 In addition, VHA pays forsome care delivered through outside providers. VHAreports that treatment for PTSD is commonly deliveredin outpatient clinics and CBOCs, either through generalmental health clinics or, less commonly, through special-ized programs provided by PTSD Clinical Teams, Sub-stance Use PTSD Teams, and Women’s Stress DisorderTreatment Teams. VHA guidelines instruct clinicians totell patients to expect about six months of treatment, butfor patients with severe cases of PTSD or multiple diag-

noses of mental health disorders, treatment may extendfor one to two years or longer. For many veterans, PTSDoscillates between remission and relapse. The NationalCenter for PTSD reports that some veterans may neverbe free of symptoms; rather, patients may learn copingmechanisms that allow them to function in private andpublic spheres. One of VHA’s treatment goals is to helpveterans develop those mechanisms.7

Treatment for PTSD is tailored to the patient and mayinclude a combination of psychotherapy (treatment basedon psychology techniques) and pharmacotherapy (treat-ment using prescription drugs). In addition, all treatmentprograms for PTSD in VHA provide education for fami-lies and veterans (including coping mechanisms).

VHA offers two forms of evidence-based psychother-apy—that is, therapy based on a substantive body ofempirical research broadly accepted by the medical com-munity. Those therapies are cognitive processing therapy(CPT) and prolonged exposure (PE) therapy. CPT helpspatients change the way the trauma is perceived—forexample, by replacing blame and guilt with less distress-

ing thoughts. In PE therapy, the traumatic events arenarrated repeatedly and combined with exercises toreduce anxiety in specific situations. The Institute ofMedicine has concluded that exposure therapies, such as

PE therapy, or other therapies that include exposure aspart of treatment, such as CPT, are the only types of psy-chotherapy that have been found effective for PTSD;however, the Institute also noted evidence that the effec-tiveness of exposure therapies for veterans is not as strongas for civilians.8 Other therapies used by VHA includegroup and family therapy.

Clinical research suggests that PTSD patients whoundergo therapy require at least nine treatment sessions.9 VHA reported to CBO that 40 percent of OCO veteransinitiating CPT or PE therapy complete a full course of

therapy. Typically, VHA patients undergoing CPT meetone on one with a therapist for an hour each week; forpatients undergoing PE therapy, VHA typically schedulesone 90-minute session each week. VHA data from inter-nal program evaluations indicate that OCO veterans whocompleted PE therapy attended an average of 11 sessions, whereas those who did not complete therapy attended anaverage of 5 sessions; results were similar for patientsundergoing CPT. Additional data from a recently pub-lished study found that 80 percent of OCO veterans whoused VHA’s services and received new PTSD diagnoses

had at least one follow-up visit; nonetheless, fewer thanhalf completed the recommended treatment sessions within one year.10 The reasons for not completing a fullcourse of therapy may include the following: the distancebetween home and the location of care, a preference forreceiving mental health care from providers outsideVHA, difficulty scheduling appointments, negative per-ceptions of mental health care, and impaired judgment asa result of either the condition itself or associated prob-lems such as substance abuse.

Pharmacotherapy in VHA consists mainly of the use

of antidepressants, such as selective serotonin reuptake6. In addition to providing clinical care services, VHA operates

about 300 Vet Centers for veterans and their families at no out-of-pocket cost. Vet Centers offer readjustment services such asindividual and family counseling, assistance in applying for VHAbenefits, and information on other community and educationalopportunities. Veterans using those services need not be enrolledfor VHA’s health care services, and they retain anonymity for anycounseling they receive.

7. For more information, see VHA’s National Center for PTSD Website at www.ptsd.va.gov/public/index.asp.

8. Institute of Medicine, Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (Washington, D.C.: National Acade-mies Press, 2008).

9. Karen Seal and others, “VA Mental Health Services Utilization inIraq and Afghanistan Veterans in the First Year of Receiving NewMental Health Diagnoses,” Journal of Traumatic Stress , vol. 23,no. 1 (February 2010), pp. 5–16.

10. Ibid.

http://www.ptsd.va.gov/public/index.asphttp://www.ptsd.va.gov/public/index.asp


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inhibitors (SSRIs) and serotonin norepinephrinereuptake inhibitors (SNRIs). If unsuccessful, treatmentmay expand to mood stabilizers, anticonvulsants, antipsy-chotics, or other agents to alleviate symptoms such asanxiety, intrusive thoughts, flashbacks, and insomnia. Inone study, VHA researchers determined that pharmaco-therapy was more likely to be prescribed for patientsreceiving a diagnosis in a mental health clinic than forthose diagnosed in a general medical or PSTD clinic.11

A small share of OCO patients with PTSD diagnosesundergoes psychiatric hospitalization—5 percent through2010. Such hospitalizations include both traditionalinpatient stays and specialized programs involving shortresidential stays; those stays involve counseling and treat-ment with social, vocational, and recreational therapies.

VHA’s Services for TBITBI is classified as mild, moderate, or severe on the basisof its severity at the time of the injury. Because moderateand severe TBIs are easily identified and require immedi-ate attention, acute care for combat-related TBIs isgiven by DoD, whereas VHA provides rehabilitationcare. Moderate and severe TBIs are clinically differentfrom mild TBIs, and their treatment typically involvessubstantially more health care resources. Veterans whoexperienced moderate or severe TBIs may receive inpa-tient rehabilitative care, outpatient rehabilitative care,

or both, through programs that specialize in treatingcomplex patients. Along with occupational, cognitive,physical, and other therapies, VHA also providesadvanced technologies to veterans with ongoing needsrelated to sensory impairment, communication deficits,mobility, and self-care. The course of treatment pre-scribed and the services provided vary significantly bypatient and are tailored to the severity of the TBI andongoing problems.

Veterans with mild TBI are also eligible for VHA’s TBIrehabilitation programs, but they are usually treated onan outpatient basis for less intense clinical symptoms andfor a much shorter duration than moderate and severeTBI patients. In April 2007, VHA directed that all OCOveterans who use VHA and have not received a priordiagnosis for TBI be screened for symptomatic TBI—

that is, TBI with currently occurring symptoms such asheadaches, memory difficulties, or sleep problems.Because moderate and severe cases are readily detected,the purpose of this screen, in effect, is to identify mild

TBI. Since April 2007, questions designed to detect TBIhave been included in VHA’s Iraq and Afghan Post-Deploy Screen. For those who screen positive, additionalevaluation takes place with the patient’s agreement; in theabsence of that consent, VHA requires that the patient’srefusal to undergo further evaluation be documented.Through 2009, approximately one in five OCO veteransscreened positive for symptomatic TBI. Two-thirds ofthose screening positive (or 14 percent of all screenedpatients) completed a comprehensive evaluation (some ofthose may not have undergone further testing becausesymptoms had resolved before the full evaluation was

conducted). Of the 14 percent receiving a comprehensiveevaluation, VHA clinicians diagnosed symptomatic TBIin one-half of those who screened positive (or 7 percentof all those initially screened).12

Some VHA medical facilities use individual neurologists,rehabilitation physicians, or psychiatrists for the follow-up evaluation, whereas others refer patients to aninterdisciplinary team. Evaluation includes a completehistory of injury, a physical exam, and a neurobehavioralinventory of TBI symptoms. Other diagnostic tools forTBI are limited. In some cases, a veteran’s medical recordsfrom DoD are incomplete or unavailable, because DoD’sand VHA’s medical systems are not fully integrated. Cor-rect diagnosis is problematic, as none of the symptomsof TBI are unique to that condition, and there is noclinically validated definition for TBI with persistentsymptoms months after injury. Thus, many of the diffi-culties in diagnosing and treating PTSD also apply tosymptomatic TBI: Some veterans may not seek care;

11. Michele R. Spoont and others, “Treatment Receipt by Veterans After a PTSD Diagnosis in PTSD, Mental Health, or GeneralMedical Clinics,” Psychiatric Services , vol. 61, no. 1 (January2010), pp. 58–63.

12. David Cifu, National Director of VA’s Physical Medicine andRehabilitation Office, “The Veterans Health Administration Poly-

trauma System of Care” (PowerPoint slides transmitted via e-mail,May 2010).There is some controversy surrounding estimates ofthe prevalence of symptomatic TBI. Headaches, concentrationand memory problems, fatigue, irritability, and sleep disturbanceare common symptoms seen in veterans returning from war, as

well as in individuals with other medical conditions. Whethersymptoms that occur months or years after a TBI can be unequiv-ocally attributed to mild TBI, as opposed to other conditions, hasbeen the subject of considerable debate. See Charles Hoge andothers, “Care of War Veterans with Mild Traumatic BrainInjury—Flawed Perspectives,” New England Journal of Medicine ,vol. 360 (April 16, 2009), pp. 1588–1591.


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there is no objective diagnostic tool to confirm thediagnosis; symptoms may coincide with those of otherconditions; and VHA’s diagnostic process often reliesheavily on the veteran’s memory, which may be impaired

as a result of TBI or another medical condition.

13

After confirmation of the diagnosis, additional physicalexaminations, laboratory tests, and psychosocial evalua-tions may be performed.14 Because there is no standardtreatment regimen, a team of clinicians typically evaluatesthe results and determines a treatment plan, whichaccounts for concurrent disorders. According to VHA’sguidelines, patients with symptoms persisting beyondfour to six weeks of treatment should be reassessed,assigned to a case manager, and receive treatment for theirremaining symptoms.

VHA considers the management of physical, behavioral,and cognitive symptoms fundamental to treatment ofmild TBI. The two mainstays of treatment are symptom-specific treatment (such as managing headache pain, themost common symptom of TBI) and educating patientson their expected recovery. VHA states that treatmentthrough primary care clinics is appropriate for managingTBI when implemented by an interdisciplinary team ofrehabilitation therapists, pharmacists, and mental healthclinicians. Pharmacotherapy is sometimes used alone orin conjunction with other therapies to treat musculoskel-etal pain, anxiety, or psychiatric symptoms. However,there is currently no clinically validated pharmacotherapyto improve neurocognitive function after a mild TBI. As with PTSD, providing education for veterans and fami-lies about TBI is an important part of treatment. VHA’sguidelines advise providers to reassure patients and theirfamilies that mild TBI is normally transient and fullrecovery without permanent damage is expected. Dura-tion of treatment for mild TBI at VHA is normally oneto three months, with follow-up four to six weeks later toconfirm recovery, which is defined as the resolution of

symptoms and normal functioning. For some patients,however, symptoms may persist beyond six months to ayear or longer. Further evaluation for other conditionsmay be indicated for persistent symptoms.

Concurrent Diagnoses of PTSD and TBITBIs sustained in Iraq or Afghanistan are often the resultof explosions and involve other injuries; moreover, PTSDhas been shown to occur more commonly in veterans with combat-related concussions (mild TBIs) than inthose with other injuries. The Institute of Medicine’sCommittee on Gulf War and Health found evidence,albeit limited, suggesting that TBI and PTSD areassociated.15 CBO’s analysis of VHA data found thatthree-quarters of OCO patients with a TBI diagnosisalso had a diagnosis of PTSD and that one-fifth of

OCO patients with a PTSD diagnosis also had adiagnosis of TBI.16

Because PTSD and TBI may generate many of thesame symptoms, a person who has both conditions maybe diagnosed for only one and not the other or, alterna-tively, diagnosed with both but have only one condition.Medical consensus is lacking on the accuracy of screeningand diagnosis for both conditions if the person has con-current PTSD and TBI. Diagnosing only one of theconditions when both are present can lead to difficulties with treatments. For example, treatments for either mildTBI or PTSD alone may not be effective for patients withboth conditions, as cognitive impairment may hinderadherence to treatment.

Polytrauma VHA uses the designation “polytrauma” to describe com-plex, severe injuries to multiple organ systems that often

13. For a more extensive discussion of the challenges that VHA clini-cians face in diagnosing TBI, see Heather Belanger and others,“The Veterans Health Administration’s System of Care for MildTraumatic Brain Injury: Costs, Benefits, and Controversies,” Jour-nal of Head Trauma Rehabilitation, vol. 24, no. 1 (2009), pp.4–13.

14. Information presented in this and the following paragraph is froma document prepared jointly by the Department of Veterans

Affairs and the Department of Defense, VA/DoD Clinical PracticeGuideline for Management of Concussion/Mild Traumatic BrainInjury , April 2009.

15. Institute of Medicine, Gulf War and Health, vol. 7, Long-TermConsequences of Traumatic Brain Injury (Washington, D.C.: National Academies Press, 2009).

16. Another study reported that among soldiers who had just returnedfrom a deployment to Iraq, about one-third who reportedsuffering a mild TBI also screened positive for PTSD. See LisaBrenner and others, “Traumatic Brain Injury, Posttraumatic StressDisorder, and Postconcussive Symptoms: Symptom Reporting

Among Troops Returning from Iraq,” Journal of Head TraumaRehabilitation, vol. 25, no. 5 (September-October 2010),pp. 307–312. There is some evidence that PTSD explains mostor all symptoms in OCO veterans with concussions. See Charles

W. Hoge and others, “Mild Traumatic Brain Injury in U.S.Soldiers Returning from Iraq,” New England Journal of Medicine ,vol. 358, no. 5 (January 31, 2008), pp. 453–463.


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result from the same event, such as an explosion. Thosemay include brain injury, amputation, hearing and visionimpairments, spinal cord injuries, and psychologicaltrauma. A small number of patients who have those com-plex injuries are treated in VHA’s Polytrauma System ofCare, which provides comprehensive, interdisciplinaryrehabilitation and other care for seriously disabledpatients. The Polytrauma System of Care includes fivePolytrauma Rehabilitation Centers for inpatient rehabili-tation, as well as secondary sites and clinical teams forpostdischarge care.17

Cooperation Between VHA and DoDSoon after the conflicts in Afghanistan and Iraq began, itbecame apparent that some wounded service members were encountering significant difficulties when makingthe transition from DoD’s health care system to VHA’s.To address those concerns, DoD and VHA haveincreased their cooperation and have devoted moreresources to encouraging service members and veterans toseek care.18

In the summer of 2007, DoD and VHA instituted the Wounded, Ill, and Injured Senior Oversight Committeeto address problems specific to those service members, which include the coordination of health care manage-ment, disability evaluation, and transition of OCO

service members’ health care from DoD to VHA.19

Thecommittee has several work groups charged with address-ing particular issues, including one that focuses on theneeds of service members and veterans with PTSD andTBI.

The Wounded Warrior Act, part of the National Defense Authorization Act for Fiscal Year 2008 (Public Law 110-181, sections 1601–1676) required DoD and VHA to

implement many initiatives, including reducing waitingtime for medical care, consolidating their disability evalu-ation systems, and establishing standards to determine whether and when wounded service members could

return to active duty. The law also mandated that theGovernment Accountability Office (GAO) deliver prog-ress reports on those initiatives to the Congress. In its July2009 report, GAO found that although DoD and VHAhad not fully developed or implemented the requirementsof the Wounded Warrior Act, they had made consider-able progress.20

DoD and VHA have targeted the coordination of healthcare management to service members with TBI or withPTSD and other mental health conditions. In particular,the agencies are collaborating on myriad issues such as

screening, diagnosing, and treating those conditions, as well as assisting service members in their transition fromDoD’s health care system to that of VHA. One result ofthat collaboration is the TBI screen used by VHA, which was derived from the screen first used by DoD at certainmilitary bases. DoD and VHA have formed joint com-mittees, such as the VHA/DoD Mental Health WorkingGroup; participate in joint research ventures, such as theDefense and Veterans Brain Injury Center; and shareclinical practice guidelines, such as Management ofConcussion/Mild Traumatic Brain Injury .21 DoD and

VHA clinicians may collaborate on service members’transition to VHA’s care; however, the proliferation ofprograms and case managers can be confusing for servicemembers and has led to some duplication of efforts.22

Because the sharing of medical records between DoD andVHA would greatly facilitate the transition of servicemembers between the agencies, the Wounded Warrior Act included provisions designed to achieve such sharing;

17. The five centers are located in Minneapolis, Minn.; Palo Alto,Calif.; Richmond, Va.; Tampa, Fla.; and San Antonio, Tex. For

more information, see VHA’s Polytrauma/TBI System of Care Web site at www.polytrauma.va.gov .

18. VHA, for example, created a Mental Health Enhancement Initia-tive to provide funding to facilitate greater community outreach,place PTSD specialists or treatment teams in each VHA MedicalCenter, and expand evidence-based care for PTSD.

19. The Wounded, Ill, and Injured Senior Oversight Committee isamong numerous review groups, task forces, and commissionsthat have examined or are currently charged with improving thecare and benefits that DoD and VA provide to service membersand veterans.

20. Government Accountability Office, DOD and VA Have JointlyDeveloped the Majority of Required Policies but Challenges Remain,

GAO-09-728 (July 2009).21. The Defense and Veterans Brain Injury Center became one of

the component centers of the Defense Centers of Excellence forPsychological Health and Traumatic Brain Injury, an umbrellaorganization that was established in November 2007. For moreinformation, see the Defense Centers of Excellence Web site at

www.dcoe.health.mil.

22. Robin M. Weinick and others, Programs Addressing PsychologicalHealth and Traumatic Brain Injury Among U.S. Military Service-members and Their Families (Santa Monica, Calif.: RANDCorporation, 2011).

http://www.polytrauma.va.gov/http://www.polytrauma.va.gov/http://www.polytrauma.va.gov/http://www.polytrauma.va.gov/http://www.dcoe.health.mil/http://www.polytrauma.va.gov/http://www.polytrauma.va.gov/http://www.polytrauma.va.gov/http://www.dcoe.health.mil/


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however, that objective remains a work in progress.DoD and VHA do have complex sharing agreements andinformation-exchange projects to coordinate their inde-pendent record systems. For example, DoD can transfer

the medical records of service members who have sepa-rated from DoD and are eligible for VHA care throughthe Federal Health Information Exchange. Moreover,health care clinicians for DoD and VHA can accessrecords for patients treated by providers in either agencythrough the Bidirectional Health Information Exchange. Yet technical and organizational challenges have made itdifficult to construct a unified electronic medical record.The Virtual Lifetime Electronic Record (VLER)—a jointeffort of DoD and VHA—overcame a major hurdle in2010 when DoD and VHA agreed to use a common per-sonal identifier. Slated for VHA-wide implementation in

2012, the VLER is a single electronic record that wouldbe used to manage comprehensive administrative andmedical information for service members throughouttheir lives, from enlistment to death, regardless of healthcare provider.

Current record-sharing goals for VHA and DoD extendto a broader effort with the private sector, the NationwideHealth Information Network (NwHIN).23 This group offederal agencies and private organizations has agreed tosecurely share patients’ health information electronicallyamong providers and health care systems by definingstandards, services, and policies. Pilot projects forNwHIN are under way; veterans who agree to participateallow their public- and private-sector health care provid-ers to share specific health information.

CBO’s Analytical Approach to VHA Data In this study, CBO presents data on the use of VHA’shealth care services between fiscal years 2004 and 2009by OCO veterans who received a diagnosis of PTSD orTBI.24,25 CBO also presents estimates of the costs that

VHA has incurred to treat OCO veterans with PTSD,TBI, or both during that period and compares them with

the costs of providing care to OCO patients who do nothave PTSD or TBI.26 CBO’s estimates are based onVHA’s cost data and do not include expenditures by otherfederal providers of health care or private insurers, out-of-

pocket costs, forgone earnings, or other losses to societyassociated with the two conditions.27

CBO’s primary analysis focused on VHA patients whohad not been treated at specialized polytrauma facilities, which provide care for veterans who suffer from morethan one complex physical or mental trauma. That analy-sis examined the use of VHA’s health care services andcost of providing those services for 496,800 OCO veter-ans in four mutually exclusive groups:

103,500 patients with PTSD (but not TBI);

8,700 patients with TBI (but not PTSD);

26,600 patients with both PTSD and TBI; and

358,000 patients with neither of those two condi-tions.28

Patients in the PTSD group did not have TBI, but manyhad other conditions; similarly, patients in the TBI groupdid not have PTSD, but many had other conditions.None of the groups includes 500 polytrauma patients,

many with PTSD and TBI, who were analyzed separately.The data include 99 percent of all OCO veterans seen byVHA from 2004 to 2009. To protect patients’ confidenti-ality, VHA did not provide CBO with data on individual

23. NwHIN is led by the Department of Health and Human Services.For more information, see http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__nhin_exchange/1407 .

24. VHA did not provide CBO with data from the start of overseascontingency operations in 2001. However, the number of OCOveterans entering VHA before 2004 was relatively small: Roughly10,000 veterans who deployed to Iraq and Afghanistan had soughtVHA’s health care services by the end of 2003.

25. Vet Centers provided PTSD services to 42,000 OCO veteransthrough June 2011; among those veterans, 27,000 were also seenfor PTSD at a VHA medical center. The data that CBO analyzeddo not include information on the 15,000 veterans seen only atVet Centers.

26. In the information that it provided to CBO, VHA converted itscost data to fiscal year 2009 dollars on the basis of annual

increases in the average cost of a primary care visit from 2004 to2009. CBO then indexed those costs to 2011 dollars using theimplicit price deflator for gross domestic product.

27. Initial hospitalizations for the more severe cases of TBI are notincluded in VHA’s costs because those individuals were still onactive duty at the time of initial injury and would have beentreated within DoD.

28. TBI describes an injury event, but the term TBI may also refer tosymptoms that persist beyond the acute period. In this study, TBIpatients are OCO veterans who, when examined at VHA facili-ties, exhibited symptoms attributed to a TBI.

http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__nhin_exchange/1407http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__nhin_exchange/1407http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__nhin_exchange/1407http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__nhin_exchange/1407


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patients. Because VHA did not identify the date ofpatients’ first diagnosis or entry, CBO was not able tocalculate the use or the cost of health care for patientsentering VHA treatment in any given fiscal year.

For the first three groups, CBO presents data on the useof services and costs of treatment for the first year of care(treatment year 1) and for up to three additional yearsfollowing initial diagnosis.29 Data on patients with nodiagnosis of PTSD or TBI are presented for comparisonpurposes following their initial visit for any VHA care.CBO did not receive detailed clinical data and thus wasnot able to construct a comparison group that was similarin all observed ways to the three groups apart from theirdiagnosis of PTSD, TBI, or both. The patients with and without PTSD or TBI were roughly similar in age, sex,

and military experience, but they differed in certain char-acteristics, particularly injuries sustained while deployedin overseas contingency operations. In general, servicemembers who had PTSD or TBI were more likely to havereceived other injuries, so the costs of care for the PTSDand TBI groups probably would have been higher even without the costs of care for PTSD and TBI. The poly-trauma group, which consisted of patients with multiplecomplex injuries requiring extended inpatient stays forrehabilitation at VHA, is examined separately later in thestudy; it was a very small group whose average medicalcosts were far higher than those of the four other groups.

CBO’s analysis is based on data from VHA’s administra-tive records from 2004 through 2009. Because somepatients started using VHA’s services partway through thesample period, not all patients were observed for the fullsix years. Indeed, CBO used only the first four years ofdata even when six years were available because data forthat longer span existed for only a small minority of vet-erans. When fewer than four years of data existed, CBO

included all of the years available. Consequently, whenCBO examined patients’ first year of treatment, those who entered the VHA system in 2008 and 2009 wereincluded, but when CBO examined later years of treat-

ment, those patients were not included, having enteredthe system too late in the sample period.

Not only do patients entering VHA in 2008 and 2009have fewer years of treatment data available, they are alsodifferent from those who entered in earlier years in twoother ways. First, more veterans entering the VHA systemin those later years had experienced longer deploymentsand multiple deployments. Second, starting in 2008,VHA extended enhanced eligibility from two years to fiveyears for OCO veterans (see Box 1 on page 2). Thatextension enabled veterans with delayed-onset PTSD or

other combat-related conditions for which they had notpreviously sought treatment to enter the VHA systemand receive care at no cost. However, CBO does notbelieve that those two differences substantially affectedthe number or severity of PTSD or TBI cases or, moregenerally, the injuries or other medical conditions treatedat VHA in 2008 and 2009.30

While screening and treatment for PTSD were consistentacross the years, VHA’s clinical practices for TBI changedduring the data period (2004 to 2009): The agency initi-ated comprehensive screening for mild, symptomatic

TBI in 2007. As a consequence, the characteristics of TBIpatients are likely to be different across treatment years.Patients whom VHA diagnosed with TBI before 2007 were more likely to have had moderate to severe TBI thanthose diagnosed in 2007 or after. The study period endedbefore the newly identified mild cases could accumulatefour treatment years. Therefore, moderate and severecases are more common among TBI patients in treatmentyears 3 and 4 than in treatment years 1 and 2. BecauseCBO did not have information on TBI severity (mild,moderate, or severe), it was not possible to separate the

29. To determine the group to which a patient belonged, each OCO

patient’s administrative record was checked for any diagnosis codeof PTSD or TBI, and the patient was assigned to the relevantgroup. Any patient with both codes was classified as having bothPTSD and TBI. No patient could be included in more than onediagnosis group; once classified, patients remained in the samegroup for the entire sample period. The sample included all PTSDand TBI cases among OCO veterans diagnosed at VHA, regard-less of whether those conditions were sustained while deployed.The share of veterans who acquired PTSD or TBI unrelated todeployment (for example, injury from an automobile accidentafter returning from Iraq or Afghanistan) is unknown but is prob-ably a small portion of CBO’s sample.

30. Veterans who became part of CBO’s sample in those later years aremore likely to have remained in the military longer after deploy-ment than those who entered in the early years of 2004 and 2005.

Any health conditions that veterans who entered VHA in 2008and 2009 developed during deployment, therefore, were morelikely to have been treated by DoD before those service memberstransferred to VHA. The extension of enhanced eligibility in 2008appears to have had a minimal effect on entry into the VHA sys-tem. VHA provided CBO with data showing that both before andafter the policy change, most veterans who used VHA services didso within two years of separation from active duty.


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use of services and costs by severity. The costs of treatingmild TBI, however, are likely to be substantially lowerthan the costs of treating moderate and severe TBI. Asa result of the policy change, use and costs in later

treatment years grow for TBI patients and are almost ashigh in treatment year 4 as in treatment year 1. Withoutthe policy change, use and costs for those patients proba-bly would have been highest during the first year of careand then declined and stabilized thereafter, as occurred inthe other groups.

VHA provided CBO with aggregate use and cost data forgroups of OCO veterans based on their demographiccharacteristics, medical condition, and medical servicesused.31 Because data were provided at the group level,CBO can only present information on averages for those

groups and not on the distribution of use or cost withingroups. (For additional information about the data andmethodology used in this analysis, see Appendix B.)

CBO calculated total and average costs for patients whoaccessed VHA’s services at least once, for up to four yearsafter their PTSD or TBI diagnoses or, in the absence ofthose diagnoses, average costs for up to four years aftertheir entry into the VHA system. Diagnostic tests andpharmacy use were included and categorized as part ofoutpatient costs. As with all analyses based on administra-tive data, errors and nonstandardized coding may affectthe results presented here.

Occurrence and Prevalence ofPTSD and TBIIn the VHA data provided to CBO regarding 496,800OCO veterans treated by VHA between 2004 and 2009,veterans with a diagnosis of PTSD (but not TBI)accounted for 21 percent (103,500) of the total, andthose with a diagnosis of TBI (but not PTSD) accountedfor 2 percent (8,700). In addition, veterans with diagno-

ses of both PTSD and TBI accounted for about 5 percent(26,600). Thus, three out of four OCO veterans with a

diagnosis of TBI had a concurrent PTSD diagnosis.32 Intotal, approximately 26 percent (130,100) had at leastone diagnosis of PTSD, and 7 percent (35,300) had atleast one diagnosis of TBI.33 More than 70 percent

(358,000) of OCO veterans treated by VHA were notdiagnosed with either PTSD or TBI. Other mentalhealth conditions besides PTSD are common within theOCO veteran population. (For a brief description ofother mental health conditions and suicide in that popu-lation, see Box 2.)

The occurrence of PTSD and TBI among OCO veterans who use the VHA system—which is measured by thediagnosis rates just described—does not necessarily reflectthe prevalence of those conditions in the entire OCOpopulation. If service members who have separated from

the military are more likely to have service-connectedhealth problems than those who have remained on activeduty, then the rate of diagnosis among VHA patients will be higher than the proportion of the entire OCOpopulation that has those problems. If, however, suffi-cient numbers of veterans with PTSD or TBI were eitherbeing treated for the condition elsewhere or not beingtreated at all, the rate in the overall OCO populationcould be greater than the rate diagnosed among VHApatients. For example, some veterans have employment-based health insurance; others seek care from other

sources that are not connected to their military service,perhaps because providers are located more convenientlyor are perceived to be more private; and still other veter-ans forgo care altogether. For PTSD, the effect of stigmaassociated with a positive screening or diagnosis has not

31. VHA computes costs on the basis of its internal reporting systems.Costs for treating PTSD and TBI in the civilian population andveterans treated at VHA are unlikely to be comparable because ofdifferences in cost allocation methodologies, the populationstreated, and the mechanisms of injury. Also, while VHA data mea-sure the costs of care, private-sector estimates are often based oninsurance reimbursements to private providers, which are notidentical to costs.

32. VHA researchers examining OCO veterans treated at VHA havereported rates of concurrent diagnoses that are similar to CBO’s;however, some researchers drawing from broader samples of OCOservice members and veterans find lower rates of concurrent TBIand PTSD. In the three studies with the largest sample sizes,between 33 percent and 39 percent of OCO veterans with mildTBI also screened positive for PTSD. See Kathleen F. Carlson

and others, “Prevalence, Assessment, and Treatment of MildTraumatic Brain Injury and Posttraumatic Stress Disorder: ASystematic Review of the Evidence,” Journal of Head TraumaRehabilitation, vol. 26, no. 2 (March–April 2011), pp. 103–115.

33. If the threshold is raised to include only veterans who had two ormore visits coded with a diagnosis of PTSD or TBI, the rates thatCBO estimates drop to 20 percent and 3 percent, respectively.(Some researchers consider a two-visit measure a more definitiveindicator of a condition, although that more-stringent threshold

will miss those veterans who have PTSD or TBI but leave theVHA system after the initial diagnosis.)


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been measured well, but it is likely to reduce the number

of people who admit to problems associated with PTSD

and then screen positive. For those reasons, the preva-

lence—that is, the estimate of the proportion of cases in a

population, whether or not the individual has received aclinical diagnosis from a medical professional—of PTSD

and TBI in the OCO population probably differs from

the percentage of patients in the VHA system diagnosed

with those conditions.

Many researchers have estimated PTSD and TBI preva-

lence among different groups of service members

and veterans who deployed to operations in Iraq and

Afghanistan, but there is no consensus as to the preva-

lence rate among the entire OCO population.34

Researchers generally have reported prevalence rates rang-ing between 5 percent and 25 percent for PTSD among

different groups of service members who deployed to

overseas contingency operations, with generally higher

rates in studies of infantry brigades or combat teams.

Researchers have found that the proportion of service

members who experienced a TBI, including those who

no longer had symptoms, ranged from 15 percent to

23 percent, and that the proportion of service members

who had symptomatic TBI after returning from deploy-

ment ranged from 4 percent to 9 percent. Thus, the

percentage of OCO veterans whom VHA clinicians

have diagnosed with PTSD (26 percent) is at the top

of the range of prevalence reported in published studies,

whereas the percentage they have diagnosed with

symptomatic TBI (7 percent) is in the middle of the

reported range. The estimates of symptomatic TBI

remain uncertain because there are no clinically validated

diagnostic criteria for that condition, and connecting

self-reported persistent symptoms to the initial injury is

problematic. Published estimates of PTSD and TBI dur-

ing deployment vary widely because the assessment toolsused to identify the conditions, the criteria used to iden-

tify cases, and the subgroup of service members sampled

differ among studies. (For a detailed discussion of those

issues, see Appendix C.)

The gold standard for determining prevalence would beto evaluate each person in a representative sample of theOCO population using validated clinical interviews;achieving that ideal, however, would be expensive and

difficult. Instead, some researchers use administrativedata on diagnoses to measure the number of cases ofPTSD and TBI; others use clinical screening tools toassess cases. Administrative data on diagnoses understateprevalence in a population because not everyone seekscare. Some researchers who use screening tools to identifyPTSD and TBI apply low thresholds for assessing those

conditions. In so doing, however, they may also generatemany false positives and overestimate the number ofcases. Conversely, researchers employing more restrictivethresholds could underestimate cases.

In addition, most studies to date, including some thatattempt to be population-based, have oversampled cer-tain groups; applying rates from nonrandom samples without the proper weighting is unlikely to yield an accu-

rate measurement of prevalence. On the one hand, esti-mates based on combat units, which experience higherrates of physical and psychological trauma than othertypes of military units, may lead to prevalence estimatesthat are too high to apply to the general population ofservice personnel in a combat region, which includes sup-port units. On the other hand, samples based on return-

ing, uninjured troops may lead to estimated prevalencerates that are too low.

Another shortcoming with published studies, whichapplies also to diagnosis rates within VHA, is that servicemembers and veterans may not accurately report theirsymptoms. The stigma associated with screening positive

for PTSD, the perceived inconvenience of undergoingadditional evaluation, or a lack of confidence in treat-ment effectiveness may lead to an underreporting ofsymptoms of mental health problems or TBI and thus

an underestimate of prevalence.

Finally, using estimates of TBIs that occur during deploy-ment is problematic because even a confirmed clinicaldiagnosis when or shortly after an injury is sustained doesnot reveal the frequency of persistent postconcussivesymptoms. DoD reports that, although a small minorityof service members has ongoing symptoms, most cases ofTBI are mild, often resolving within weeks and almost

always improving within three months.

34. Those studies included papers that reported frequencies of possi-ble cases of PTSD or TBI regardless of whether the objective ofthe study was to estimate the prevalence in the broader OCOpopulation.


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Continued

Use of VHA’s ServicesThrough September 2011, VHA reported that the num-ber of OCO veterans who had used VHA at least oncetotaled nearly 740,000, or 53 percent of OCO veterans.The OCO population using VHA’s services tends to bemale (88 percent), is young (46 percent are younger

than 32), consists predominantly of former soldiers inthe Army (61 percent), and is slightly more likely to beveterans of active-duty units (56 percent) than reservecomponents.

Future spending on OCO patients will change accordingto the mix of conditions diagnosed and the number of

Box 2.

Suicide and Mental Illness Among OCO Veterans

Just over half of veterans of overseas contingencyoperations (OCO) treated by the Veterans Health Administration (VHA) have a diagnosis of a mentalillness. Mental health problems can affect all aspectsof life. Suicide among service members and veterans,an infrequent but devastating outcome of mental ill-ness, is of particular concern to policymakers andothers.

SuicideIn 2009, the suicide rate for military members serv-

ing on active duty was 18.3 per 100,000, the highestsince 1980. The following year, that rate dropped to17.0. In the general population, by comparison, thesuicide rate in 2007 was 20.8 among males ages 20 to24 and 20.7 among males ages 25 to 34.1 From 2003to 2010, the Department of Defense (DoD) con-firmed nearly 2,000 suicides among active-duty ser-vice members, 300 of which occurred during deploy-ment. Roughly 50 percent of suicides in 2010occurred among military members who had deployedto overseas contingency operations. Suicide rates werehigher in the Army and Marine Corps than in other

branches of the military.

Suicides among service members who deployed tooverseas contingency operations also occur after theyleave military service. Studies of Vietnam veteransreveal that deployment to a war zone is associated with suicide in the years immediately followingdeployment.2 However, information on suicidesamong veterans is less complete than it is for active-

duty personnel, and no nationwide surveillancesystem exists for tracking the incidence of suicides inthat population.

The Centers for Disease Control and Prevention(CDC) compiles national statistics on suicide,but veteran status and the cause of death are notalways reported correctly on death certificates orsummarized accurately by local health officials.CDC estimates that about 35,000 suicides occurredin the U.S. population in 2007. A separate system,the CDC’s National Violent Death ReportingSystem—which maintains more comprehensive dataon violent deaths but operates in only a limitednumber of states—estimates that veterans accountedfor 20 percent of the suicides in those states in 2005.The CDC and Department of Veterans Affairs haveongoing initiatives to tabulate all suicides amongveterans.

Statistics from VHA’s suicide-prevention coordina-tors indicate that in fiscal year 2009 there were nearly11,000 suicide attempts among veterans receiving

care from the agency; 6.2 percent were documentedas fatal. Among VHA’s patients in 2007, the rate ofsuicide was 35 per 100,000, a rate higher than thatfound in the general population. However, that rate isnot adjusted for the demographics of VHA’s userpopulation. Veterans who use VHA, moreover, maydo so because they have more medical conditions,including mental health conditions, than other veter-ans or members of the general population.

1. Historically, rates of death for all causes have been loweramong service members than in the general population.

2. Institute of Medicine, Gulf War and Health, vol. 6, Deployment-Related Stress and Health Outcomes (Washington,D.C.: National Academies Press, 2007).


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patients treated.35 CBO’s estimates of diagnosis rates are

useful in projecting VHA’s future costs, but the usefulness

depends on the extent to which the prevalence of thoseconditions and veterans’ likelihood to seek treatment atVHA remain the same. If outreach services motivatemore veterans to seek care, for example, the rate at whichveterans use VHA’s services would tend to increase overtime. Combat exposure should decline with OCO troop

Box 2. Continued

Suicide and Mental Illness Among OCO Veterans

As part of VHA’s expansion of mental health services,the agency’s suicide-prevention program is wide-ranging.3 Initiatives include screening OCO veteransfor selected mental health conditions; establishingsuicide-prevention programs in each VHA hospitaland large community-based outpatient clinic; operat-ing a 24-hour suicide-prevention hotline staffed byVHA mental health professionals; and developing asystem for flagging the records of patients at high riskof suicide.

Mental Illness Among OCO veterans using VHA’s services fromOctober 2001 through June 2011, 21 percent werediagnosed with a depressive disorder. Other mentalhealth conditions commonly diagnosed amongOCO veterans are anxiety and drug or alcohol abuse.OCO patients with mental health conditions oftenhave multiple conditions of this type.

Treatment for mental illness is provided at localfacilities in broad consultation with VHA’s Officeof Mental Health Services, which has been imple-

menting recommendations from its comprehensivefive-year Mental Health Strategic Plan. That plan, which focused on gaps in mental health care for vet-erans, had several goals, which included addressingthe mental health needs of OCO veterans and pre-venting suicide. One of the steps being taken toachieve those goals is to better integrate mentalhealth treatment and primary care. For fiscal year2010, VHA obligated $5.2 billion for mental healthprograms—more than a tenth of its total spending

for medical care; obligations are slated to exceed$6 billion by 2012.4 Available services consist of out-patient specialty programs, inpatient psychiatric care,residential and vocational rehabilitation, substanceuse disorder care, and various local initiatives.

VHA provided CBO with information on the use ofVHA’s health care services and the costs of providingthose services for 73,000 OCO veterans who had amental health diagnosis other than PTSD (and nodiagnosis of TBI). When compared with OCOveterans with no mental health diagnosis, patients with mental health disorders other than PTSD madegreater use of VHA’s health services in treatmentyear 1 as measured by inpatient hospital days (0.6 peryear compared with 0.08 per year for veterans withno mental health diagnosis), annual outpatient visits(16 versus 8), and prescriptions filled (9 versus 3). When compared to OCO patients with PTSD,patients with other mental health conditions spentthe same share (one-quarter) of their hospital days inpsychiatric care but used less health care overall. Forthe first year of treatment, VHA spent $350 million

on patients with other mental health diagnoses. Theaverage cost of care during the first year of treatment($4,300) was more than double that for OCOpatients with no mental health diagnoses ($2,000)but only half the average cost of treating OCOpatients with PTSD.

3. See the Joshua Omvig Veterans Suicide Prevention Act (P.L.110-110, 38 U.S.C. 1720F).

4. An obligation is a commitment that creates a legal liabilityon the part of the government to pay for goods and servicesordered or received. Such payments may be made immedi-ately or in the future. Obligations during any year mayexceed appropriations provided during that year becausean agency may obligate funds that were provided in anearlier year.

35. For a discussion of future spending on health care for OCO veter-ans, see Congressional Budget Office, Potential Costs of Veterans’Health Care (October 2010).

http://www.cbo.gov/doc.cfm?index=11811http://www.cbo.gov/doc.cfm?index=11811http://www.cbo.gov/doc.cfm?index=11811http://www.cbo.gov/doc.cfm?index=11811


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levels, however, so fewer service members are likely todevelop PTSD or TBI in the future. In addition, anincreasing share of veterans who do seek care from VHAin the future will have deployed several years earlier and

are more likely to have sought care through DoD or tohave had their symptoms resolve than was the case forveterans who sought care from VHA before 2010. Forthose reasons, future veterans enrolling in VHA’s healthcare system are less likely to seek treatment for PTSD orTBI.

CBO measured the use of services by the number ofpatients who used VHA’s services after a diagnosis ofPTSD or TBI and by the frequency of their use afterthose diagnoses. CBO measured VHA’s services in threecategories: inpatient care (in days), outpatient care (in

number of clinic visits), and pharmacy services (in 30-dayequivalent prescriptions filled). CBO calculated the aver-age use by service type in each treatment year for veterans who ever used VHA’s services.

Patients who had PTSD, TBI, or both conditions usedthe VHA system much more in any given year and weremore likely to use VHA’s services than were patients withneither diagnosis. (This section of the analysis focuses onall health care services provided to patients in each group,regardless of whether a particular service was related to aPTSD or TBI diagnosis.) CBO found the highest average

use of all health care services among patients who weretreated for both PTSD and TBI. The use of services byTBI patients was roughly comparable to that of PTSDpatients in the first two treatment years, but TBI patients(probably those with moderate to severe TBI) had mark-edly higher inpatient and outpatient use in treatmentyears 3 and 4. With the implementation of comprehen-sive screening for mild TBI in 2007, patients withmoderate to severe TBI accounted for a larger share ofcases in treatment years 3 and 4. Veterans with neithercondition used VHA the least, with little change over thefour treatment years. Use of services for most groups was

highest in the first year of care.

Number of Patients Using VHA’s ServicesThe share of veterans who continued to access care atVHA declined in the years following their initial use of itsservices; however, the rate of decline differed among thegroups CBO analyzed. The largest decrease occurred inthe group that had no diagnosis of either PTSD or TBI;less than half (42 percent) of those veterans continued touse VHA four years after initial use (see Figure 1).

Figure 1.

Continuation of Use of VHA’s Services byOCO Veterans

(Percent)

Source: Congressional Budget Office based on data from the

Department of Veterans Affairs, Veterans Health

Administration.

Notes: For treatment years 2 through 4, the share of patients

treated by VHA represents the number of patients using

VHA’s services divided by the number of potential

patients—those who were diagnosed with the condition

in treatment year 1 and who remain in the sample

(see Table D-1).

Data cover fiscal years 2004 to 2009 for up to the first four

years of treatment. Data exclude about 500 patients, many

with PTSD and TBI, who entered VHA at Polytrauma

Rehabilitation Centers.

VHA = Veterans Health Administration; OCO = overseas

contingency operations; PTSD = post-traumatic stress

disorder; TBI = traumatic brain injury.

a. Patients in the PTSD group did not have TBI, but many had

other conditions.

b. Patients in the TBI group did not have PTSD, but many had other

conditions.

By contrast, at least two-thirds of veterans in the otherthree groups continued to use VHA for some of theirhealth care four years after initial diagnosis. Thosepatients might have had more clinically complicated con-ditions that took longer to resolve. In addition, thosepatients’ more intensive initial use of services might havepredisposed them to continue pursuing care. Because oftheir conditions, moreover, some patients could also havehad limited opportunities for employment, a commonsource of alternative health care options.

Treatment

Year 1

Treatment

Year 2

Treatment

Year 3

Treatment

Year 4

0

20

40

60

80

100

120

PTSDa

No PTSD or TBI

Both PTSD and TBI

TBIb


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Figure 2.

Use of VHA’s Health Care Services by OCO Patients(Average number)

Source: Congressional Budget Office based on data from the Department of Veterans Affairs, Veterans Health Administration.

Notes: Data cover fiscal years 2004 to 2009 for up to the first four years of treatment. Data exclude about 500 patients, many with PTSD and

TBI, who entered VHA at Polytrauma Rehabilitation Centers.

Average annual use is based on the number of OCO patients who were ever seen at VHA, regardless of whether they were treated in a

given year.

VHA = Veterans Health Administration; OCO = overseas contingency operations; PTSD = post-traumatic stress disorder;

TBI = traumatic brain injury.

a. “Prescriptions filled” includes all pharmacy services, such as dispensing of pharmaceuticals and over-the-counter drugs (measured in

30-day equivalents), as well as related supplies.

b. Patients in the PTSD group did not have TBI, but many had other conditions.

c. Patients in the TBI group did not have PTSD, but many had other conditions.

Frequency of UseOCO veterans using any health care services at VHA at

least once, for up to four years after diagnosis or entry

into the system, were included in the calculations. Gener-ally, OCO patients used VHA’s services most intensively

in the first year of treatment, after which use declined and

stabilized (see Figure 2). The most notable exception was

for patients with TBI (including those with both PTSD

and TBI); their average use in each service category

increased in treatment years 3 and 4. Patients who had

neither a diagnosis of PTSD nor a diagnosis of TBI aver-

aged many fewer inpatient days, outpatient visits, and

pharmacy prescr

Documents

Veterans Health PTSD 2012